Jürgen Schreieck

Renal sympathetic denervation for treatment of electrical storm: first-in-man experience

IntroductionSympathetic activity plays an important role in the pathogenesis of ventricular tachyarrhythmia. Catheter-based renal sympathetic denervation (RDN) is a novel treatment option for patients with resistant hypertension, proved to reduce local and whole-body sympathetic activity.MethodsTwo patients with chronic heart failure (CHF) (non-obstructive hypertrophic and dilated cardiomyopathy, NYHA III) suffering from therapy resistant electrical storm underwent therapeutic renal denervation. In both patients, RDN was conducted with agreement of the local ethics committee and after obtaining informed consent.ResultsThe patient with hypertrophic cardiomyopathy had recurrent monomorphic ventricular tachycardia despite extensive antiarrhythmic therapy, following repeated endocardial and epicardial electrophysiological ablation attempts to destroy an arrhythmogenic intramural focus in the left ventricle. The second patient, with dilated nonischemic cardiomyopathy, suffered from recurrent episodes of polymorphic ventricular tachycardia and ventricular fibrillation. The patient declined catheter ablation of these tachycardias. In both patients, RDN was performed without procedure-related complications. Following RDN, ventricular tachyarrhythmias were significantly reduced in both patients. Blood pressure and clinical status remained stable during the procedure and follow-up in these patients with CHF.ConclusionOur findings suggest that RDN is feasible even in cardiac unstable patients. Randomized controlled trials are urgently needed to study the effects of RD in patients with electrical storm and CHF.

Contact force–controlled zero-fluoroscopy catheter ablation of right-sided and left atrial arrhythmia substrates

BACKGROUND Conventional catheter ablation of cardiac arrhythmias is associated with radiation risks for patients and laboratory personnel. However, nonfluoroscopic catheter guidance may increase the risk for inadvertent cardiac injury. A novel radiofrequency ablation catheter capable of real-time tissue-tip contact force measurements may compensate for nonfluoroscopic safety issues. OBJECTIVE To investigate the feasibility of contact force-controlled zero-fluoroscopy catheter ablation. METHODS In 30 patients (including 12 pediatric patients), zero-fluoroscopy catheter ablation of right-sided (right atrium, n = 20; right ventricle, n = 2) and left atrial (n = 8) arrhythmias was attempted. Inclusion criteria were symptomatic suspected atrioventricular nodal reentrant tachycardia, atrioventricular reentrant tachycardia, focal right atrial and ventricular arrhythmias, and lone atrial fibrillation. A novel irrigated-tip catheter with an integrated contact force sensor was used for nonfluoroscopic 3-dimensional electroanatomical mapping and radiofrequency ablation. Transseptal access was gained under transesophageal guidance for ablation of left-sided arrhythmias. RESULTS Procedural success without fluoroscopy was achieved in 29 of the 30 patients (97%). In 1 patient, endocardial nonfluoroscopic ablation failed because of an epicardial accessory pathway within a coronary sinus aneurysm. Mean total contact force and amplitude of force undulations were kept below 50 g during mapping and below 40 g during ablation to prevent contact force peaks (>100 g). Apart from a transient second-degree type I atrioventricular block, no complications occurred. The mean procedure time was 2.8 ± 0.9 hours. There were no arrhythmia recurrences during a mean follow-up of 6.2 ± 4.2 months. CONCLUSION Contact force-controlled zero-fluoroscopy catheter ablation is generally feasible in right-sided and left atrial cardiac arrhythmias.

Relationship between surface electrocardiogram characteristics and endocardial activation sequence in patients with typical atrial flutter

Die Darstellung von Vorhofflattern im Oberflächen-EKG ist durch endokardiale Registrierungen bisher noch nicht zufriedenstellend geklärt. Ziel der Studie war die Untersuchung der Zusammenhänge zwischen endokardialer Erregungsausbreitung und dem Oberflächen-EKG bei Patienten mit Vorhofflattern.¶   Methoden: Bei 40 Patienten mit Vorhofflattern wurde bei der elektrophysiologischen Untersuchung ein 64-poliger Basketkatheter in den rechten Vorhof und ein 10-poliger Katheter in den Koronarsinus eingebracht. Die zeitliche Beziehung zwischen endokardialer und Oberflächen-EKG-Aktivierung wurde analysiert.¶   Ergebnisse: Bei Vorhofflattern im Gegenuhrzeigersinn bedingt die Aktivierung der Lateralwand des rechten Vorhofs die positive Deflektion in Ableitung I, V1 und V6 und die aufsteigende Komponente in den inferioren Ableitungen. Die Plateau-Dauer in Ableitung III (121±27ms) korreliert mit der endokardialen Isthmusleitungszeit (117±23ms) (r=0,91). Die septale und linksatriale Erregungsleitung bedingt eine negative Komponente in Ableitung I, II, III, aVF und V6 und eine positive Deflektion in aVL und V1. Bei Vorhofflattern im Uhrzeigersinn zeigt die F-Welle in allen Ableitungen eine „Einkerbung”“. Die erste Komponente ist bedingt durch die Aktivierung des Septums und der posterioren Wand des rechten Vorhofs, die zweite Komponente entspricht der zeitgleichen Aktivierung des Koronarsinus. Das Intervall zwischen den zwei Deflektionen (60ms ±18ms) korreliert mit der interatrialen Leitungszeit (57±19ms) (r=0,84). Die interatriale Leitungszeit war bei Vorhofflattern verlängert im Vergleich zu Sinusrhythmus (60±18ms vs 43±13ms, P=0,04). Die Aktivierung der lateralen Wand des rechten Vorhofs generiert die negative Komponente in den Ableitungen I, II, III, aVF und V6.¶   Schlussfolgerungen: Das Oberflächen-EKG korreliert eng mit der endokardialen Aktivierung in verschiedenen Anteilen der Vorhöfe. Die Polarität der F-Welle im Oberflächen-EKG ist durch die gegenläufige Aktivierung der lateralen Wand des rechten Vorhofs und des linken Vorhofs bestimmt. Objectives: The relationships that exist between endocardial and surface electrocardiogram (ECG) activity in patients with AFl have not been satisfactorily delineated. The aim of the study was to determine the relationships that exist between the atrial endocardial activity and the surface ECG in patients with atrial flutter (AFl).¶   Methods: In 40 patients with AFl, a 64-electrode basket catheter (BC) was deployed in the right atrium (RA). A decapolar catheter was inserted into the coronary sinus (CS) to record from the left atrium. The temporal relationship between endocardial and surface ECG activity was determined by means of electronic calipers. ¶   Results: In counterclockwise AFl, the activation of the lateral wall of RA coincided with the positive deflections in lead I, V1 and V6 and the upstroke component in inferior leads. Plateau duration in lead III (121±27ms) correlated strongly with isthmus conduction time (117±23ms) (r=0.91). Septal and left atrial conduction coincided with negative components in lead I, inferior leads and V6 and positive deflections in leads aVL and V1. ¶In clockwise AFl, the F wave was notched in all ECG leads. The first component resulted from the activation of the septum and posterior wall of the RA. The second component was coincident with activity recorded in CS electrograms. The interval between the two deflections (60±18ms) correlated strongly with interatrial conduction time (57±19ms) (r=0.84). Interatrial conduction interval was prolonged during AFl as compared to sinus rhythm (60±18ms vs 43±13ms, p=0.04). Activation of the lateral wall of RA coincided with the negative components in lead I, inferior leads and V6.¶¶   Conclusions: The electrical activity in surface ECG closely correlates with conduction in specific parts of the atria. Polarity of the F wave in an ECG lead is determined by a resultant of opposing activities from the lateral wall of the RA and the left atrium.

Insertable cardiac monitors after cryptogenic stroke – a risk factor based approach to enhance the detection rate for paroxysmal atrial fibrillation

Recently, the CRYSTAL AF trial detected paroxysmal atrial fibrillation (AF) in 12.4% of patients after cryptogenic ischaemic stroke (IS) or cryptogenic transient ischaemic attack (TIA) by an insertable cardiac monitor (ICM) within 1 year of monitoring. Our aim was (i) to assess if an AF risk factor based pre‐selection of ICM candidates would enhance the rate of AF detection and (ii) to determine AF risk factors with significant predictive value for AF detection.

Percutaneous mitral valve repair using the MitraClip in acute cardiogenic shock

Sirs: Percutaneous mitral valve repair using the MitraClip system (Abbott Vascular) is a rapidly developing therapeutic approach for selected patients suffering from mitral valve regurgitation [1, 2]. Recently, the Endovascular Valve Edge-to-Edge Repair STudy (EVEREST) II has randomly compared catheter-based versus surgical treatment showing promising results for the catheter-based procedure [2]. However, EVEREST II had stringent inclusion criteria, such as left ventricular ejection fraction (LVEF) [25% and left ventricular endsystolic diameter (LVESD) B55 mm and thus may have excluded a substantial number of patients who may benefit from this technology. Recently, Franzen et al. have widened the inclusion criteria and described the feasibility of this procedure in patients at high surgical risk based on the EuroSCORE and patients with severe LV dysfunction [3]. To our knowledge, there exists no published experience in the application of the MitraClip procedure in patients with cardiogenic shock. Here, we present a case of a 51-year-old man with acute cardiogenic shock and multiorgan failure who was referred for implantation of a cardiac-assisted device as bridge to transplantation. The patient suffered from ischemic cardiomyopathy due to two severe anterior wall infarctions in 2008 and 2010 and had undergone ICD implantation in 2010. On admission, the patient presented with progressive cardiogenic shock associated with acute renal failure and beginning liver failure (see Table 1). Transthoracic echocardiography revealed a severely compromised LVEF (15%) and a severe functional mitral regurgitation (MR) grade IV due to left ventricular dilatation (LVESD 58 mm, LVEDD 67 mm). The patient required increasing doses of catecholamines for circulatory support. Initially, dobutamine was started but did not achieve sufficient blood pressure. Adrenaline followed by levosimendane was initiated to increase inotropy in combination with the insertion of an intraaortic balloon pump (IABP) to decrease the afterload. This regimen achieved a transient stabilization. However, the patient could not be continuously weaned from this circulatory support over a period of 10 days requiring repeated intubation and ventilation for lung edema. To further stabilize the patient, we decided to perform a ‘‘rescue’’ MitraClip procedure as a bridge to transplantation procedure. Under the support of the IABP, real-time 3D and 2D-transesophageal echocardiographic and fluoroscopic guidance, the clip was successfully implanted (see Fig. 1) resulting in a reduction of MR grade IV to I–II. Immediately at the end of the procedure, cardiac output improved from 3.0 to 4.3 l min and the blood pressure increased from 100/50 to 124/80 mmHg. Consistently, hemodynamic analysis showed a decrease of the PCWP from 36 to 29 mmHg and a decrease of the PAP from 75/44 to 66/37 mmHg. After 4 h, the patient was extubated and recovered quickly. He was discharged on day 7 after mitral clipping in a clinically stable condition. In the subsequent 3 months, the patient regularly presented in our outpatient clinic for clinical and echocardiographic follow-up [4]. His condition had improved to NYHA functional class II and a consistent MR grade I–II which was associated with improved laboratory parameters (see Table 1). Listing for heart transplantation was withdrawn. C. S. Zuern J. Schreieck H. J. Weig M. Gawaz A. E. May (&) Department of Cardiology, University Hospital of Tubingen, Otfried Muller-Strasse 10, 72076 Tubingen, Germany e-mail: may_andreas@yahoo.de

Frequency dependence in the action of the class III antiarrhythmic drug dofetilide is modulated by altering L-type calcium current and digitalis glucoside.

We investigated how modulation of L-type calcium current affects the class II antiarrhythmic effect of dofetilide. Action-potential duration (APD) was determined in guinea pig papillary muscle by microelectrode techniques at different stimulation frequencies (0.5-3 Hz). The APD-prolonging effect (deltaAPD) of 10 nM dofetilide was reversed frequency dependent; it was 51 +/- 6 ms at 0.5 Hz and lower at 3 Hz, 21 +/- 3 ms. Either 10 microM diltiazem or 0.1 microM Bay K 8644 (BayK) was added to decrease or increase L-type calcium currents. In the presence of dofetilide + diltiazem, deltaAPD was reduced to 32 +/- 4 ms at 0.5 Hz but not affected at 3 Hz. Conversely, dofetilide + BayK further prolonged deltaAPD to 78 +/- 10 ms at 0.5 Hz but not at 3 Hz. When 10 microM dihydroouabain, a digitalis glucoside, was added to dofetilide, deltaAPD was more pronounced at 0.5 Hz and reduced at 3 Hz. We conclude that the reversed frequency-dependent effect of dofetilide on APD can be modulated by altering L-type calcium currents. With reduced calcium current, the frequency profile is less reversed and more favorable. The similarity of BayK and dihydroouabain in aggravating the reversed frequency-dependent effect of dofetilide is in line with a contribution of intracellular calcium to this reversed rate-dependent profile in the guinea pig ventricle.

Rate-independent effects of the new class III antiarrhythmic agent ambasilide on transmembrane action potentials in human ventricular endomyocardium

The electrophysiologic effects of ambasilide, a new class III antiarrhythmic drug reported to be a nonselective blocker of both components (I(Kr) and I(Ks)) of the delayed-rectifier potassium current (I(K)) and other repolarizing potassium currents (I(tol), I(so)), were studied in specimens of left ventricular endomyocardium of human hearts obtained from 10 patients undergoing either heart transplantation (n = 4) or mitral valve replacement (n = 6). We recorded transmembrane action potential (TAP) characteristics at different stimulation frequencies (0.5, 1, 1.5, and 2 Hz) and with different dosages of ambasilide (1, 10, and 50 microM) by using conventional microelectrode techniques. Beginning at a concentration of 10 microM ambasilide, the TAP duration at 90% repolarization (TAPD90) was significantly prolonged and independent of stimulation frequency with a mean percentage prolongation of 18% at 10 microM and 30% at 50 microM ambasilide. TAP duration at 50% repolarization was not significantly prolonged except for 10 microM ambasilide at 0.5 Hz (17%; p < 0.05). The frequency-independent action potential (AP) prolongation by ambasilide in human ventricular endomyocardium indicates that a nonselective block of repolarizing potassium currents seems to be more favorable than a selective block of I(Kr).

Left ventricular site-directed biopsy guided by left ventricular voltage mapping: A proof of principle

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Reverse left ventricular remodeling after percutaneous mitral valve repair: Strain analysis by speckle tracking echocardiography and cardiac magnetic resonance imaging

Strain analysis by speckle tracking echocardiography and cardiac magnetic resonance imaging Christine S. Zuern , Patrick Krumm , Thomas Wurster , Ulrich Kramer , Jürgen Schreieck , Andreas Henning , Axel Bauer , Meinrad Gawaz , Andreas E. May a,⁎ a Medizinische Klinik III, Eberhard Karls Universität Tübingen, Germany b Diagnostische und Interventionelle Radiologie, Eberhard Karls Universität Tübingen, Germany

A novel technique for zero-fluoroscopy catheter ablation used to manage Wolff-Parkinson-White syndrome with a left-sided accessory pathway.

Conventional catheter ablation of cardiac arrhythmias is associated with the potential adverse effects of low-dose ionizing radiation on both patients and laboratory personnel. Due to the greater radiation sensitivity and the longer life expectancy of children, reduction of radiation exposure for them is of particular importance. A novel technique for zero-fluoroscopy catheter ablation is described using real-time tissue-tip contact force measurements for a 10-year-old boy who had Wolff–Parkinson–White syndrome with a left-sided accessory pathway.